Factors associated with underutilization of cervical cancer screening services among HIV positive women in Serenje District, Central Province

doi:10.21203/rs.3.rs-3346133/v1

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Research Article

Factors associated with underutilization of cervical cancer screening services among HIV positive women in Serenje District, Central Province

https://doi.org/10.21203/rs.3.rs-3346133/v1

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Cervical cancer is the most common cancer among women living with Human Immunodeficiency Virus (UNAIDS 2019⁵⁹). An estimated 604,000 new cases were diagnosed globally and an estimate of 342,000 deaths recorded in 2020 (Sung et al., 2021). According to WHO (2020⁵⁶) about 6.5% of all female cancers are cervical cancer related and 5% of cases are attributable to HIV. Zambia is ranked second on incidences of Cervical Cancer and mortality is estimated at 1,839 (WHO, 2020³⁰). Current utilization of cervical cancer screening services (CCSS) in Zambia among HIV positive women at 27%, implies underutilization (UNAIDS 2019⁵⁹). HIV Positive women in Serenje District have not been utilizing the services, as the percentage (25.8) of women accessing the service is low. This study determined factors associated with underutilization of Cervical Cancer Screening Services (CCSS) among HIV + women in Serenje district.

Methods; Descriptive cross-sectional study was conducted involving 303 HIV positive women in Serenje District of central province, Zambia. Systematic random sampling was used to recruit respondents from selected facilities and a structured questionnaire used for data collection. Statistical Software (STATA V 15), Univariate/bivariate and multivariable logistic regressions were performed to determine associations between variables.

Results; Utilisation of CCSS in Serenje District was low. Only 42.24% of respondents reported utilizing the service. Being far from a healthcare facility [AOR: 0.49 (P < 0.036, 95% CI 0.25–0.96)], having low/inadequate knowledge [AOR: 0.26 (P < 0.001, 95% CI 0.13–0.54)], Low income [AOR: 0.16 (P < 0.001, 95% CI 0.06–0.37)] and attitude of women on CCSS [AOR: 0.26 (P < 0.001, 95% CI 0.12–0.53)] contributed to reduced utilisation.

Conclusion; low knowledge, poor attitude and far distances to facilities as well as poor socio economic status were found to be the contributing factors to underutilization of the CCSS. In order to take the CCSS as closer to the communities as possible, it is recommended that the District designs and implements awareness campaigns on cervical cancer screening service; engages in outreach awareness campaigns; and conducts screening camps.

Cervical cancer is the most common cancer among women living with Human Immunodeficiency Virus (HIV). It is preventable and curable if diagnosed and treated early (UNAIDS 2019⁵⁹). About 70% of all cervical cancers and pre-cancerous cervical lesions result from sexually transmitted Human Papilloma Viruses (HPV) types 16 and 18 (WHO, 2020⁷²).

According to WHO (2020⁵⁶), an estimate of 604,000 women were diagnosed with cervical cancer globally. About 6.5% of all female cancers and 5% of cases are attributable to HIV. HIV contributes to above 40% of the cervical cancer in eight sub-Sahara African countries. Despite their increased risk, women living with HIV in sub-Sahara Africa have continued to experience limited access to regular screening for cervical cancer (UNAIDS, 2019⁵⁹).

According to WHO (2020²⁷), about 85% of sub-Saharan African women with cervical cancer had HIV. Countries with the highest rates of cervical cancer according to the age-standardized rate per 100,000 were Swaziland at (75.3%), Malawi (72.9%), and Zambia (66.4%) in the year 2018 (Bray, 2018²¹). The World Health Organization has recommended the simple, low-cost visual inspection with acetic acid (VIA) as the best screening mechanism for developing countries. Utilization of screening services among women living with HIV aged 30–49 years remains low in Malawi (19%) and 27% in Zambia (UNAIDS, 2019⁵⁹).

In Zambia, cervical cancer represents 34.3% of all cancers, making it the highest cancer problem in the country (Kalubula et al., 2018²⁰). The incidence cervical cancer rate at 58.4 per 100,000, mortality rate at 36.2 per 100,000 (Venturas. et al., 2017¹⁹) remain unacceptably high. The Ministry of Health in Zambia started cervical cancer screening services in 51 hospitals across the country. The aim was to reduce cervical cancer-related death by 25% by 2025 (MOH, 2016⁵⁸). However, Serenje, being among the first pioneer districts in Central province has continued to experience low service uptake. A total number of 1294 out of 4997 women living with HIV were screened in 2020 (SDH, 2021), which is relatively low unopposed to the other districts in the same province. Therefore, this study determined factors associated with underutilization of Cervical Cancer Screening services among HIV-positive women aged 18–69 years old in the District.

Study Design

A cross section study design was used. This design allowed the researcher to compare different variables at a point in time.

Study Setting

The study setting was Serenje district and the study involved eight (8) Health centres offering Anti-Retroviral Treatment Services in District.

Study population

The study population included HIV Positive women aged 18 to 69 years old, living with HIV and attending routine HIV treatment services at different selected study sites or Public health facilities within Serenje District namely Muzamani, Mulilima, Nchimishi, Chibale, Kabundi, Serenje Hahc, Kabamba and Serenje District Hospital.

Inclusion Criteria

Women of 18 to 69 years old, who met the following Criteria; residents of Serenje District, living with HIV positive, present at the time of interview and had lived in Serenje for at least 12 months were included in the study.

Exclusion Criteria

The researcher excluded women who were below 18 and above 69 years of age, women who had hysterectomy with removal of the uterine cervix; women with mental or physical limitations and unable to respond to the questions.

Sample Size determination

The sample size was determined by using the prevalence formula. According to the Zambian fact sheet 2019, a total of 27% women living with HIV utilized the services (UNAIDS, 2019).

n = sample size, Z (Confidence level of 95%) = 1.96, (Margin of error) e = 0.05, prevalence = P. Total sample size was = 303

$$\text{n}=\frac{{z}^{2} p\left(1-p\right)}{{e}^{2}}$$

Sampling Method

Systematic random sampling was used to select respondents at different selected study sites. The calculated sample size (No. 303) was proportionally allocated based on the number of HIV positive women to each facility. Therefore, Probability Proportion to Size (PPS) formula was used as shown below;

Number of participants per facility=$\frac{\text{t}\text{o}\text{t}\text{a}\text{l} \text{H}\text{I}\text{V} \text{p}\text{o}\text{s}\text{i}\text{t}\text{i}\text{v}\text{e} \text{w}\text{o}\text{m}\text{e}\text{n} \text{p}\text{e}\text{r} \text{f}\text{a}\text{c}\text{i}\text{l}\text{i}\text{t}\text{y}}{totalHIV positive women in eight study sites}x total sample size$

The sampling interval (Kth) for each facility was determined by dividing the average number of HIV positive women attending ART clinic for the past 3 month (sampling frame = N) by the required sample size for each facility (n), therefore the formula;

Kth =$\frac{average monthly attendant of HIV+women at ART clinic \left(N\right)}{sample size per facility \left(n\right)}$

On each day of data collection, we randomly selected the first respondent and then selected every Kth eligible respondent, who attended the clinic in their order of arrival, until the required sample size for each individual facility was fulfilled.

Data Collection Tool

A Researcher administered questionnaire was used to obtain data from 303 respondents aged 18–69 years old. This ensured capturing correct data in keeping with what is stated in the questionnaire. A structured questionnaire consisting of closed ended questions was used to capture data on variables such as age, distance to health facility, education, and marital status etc.

Data Analysis

The data collected from interviews was entered in Microsoft Excel. Cleaning of data and checking for errors was carried out; and later exported to Statistical Software, (STATA V.15) for analysis. Descriptive statistics was used to summarise the data for categorical variables and reported in frequencies and percentages for example Education level, marital status etc. Chi-square test was used to test for association between the outcome and different categorical independent variables at unadjusted level for example association between utilization of the screening method and knowledge.

Multiple or multivariable logistic regression, was used to predict the relationship between predictors (independent variables) and the predicted variable (dependent variable). Variables having a P-value of less than 0.05 at bivariate logistic regression analysis (unadjusted level) were fitted into the multivariable logistic regression model. The 95% confidence interval of odds ratio was computed and variables having P-value less than 0.05 in the multivariable logistic regression analysis were considered as statistically significant.

Characteristics of the study Participants

A total of 303 HIV positive women participated in the study, of which 128 (42.24%) of the respondents utilized the cervical cancer screening services and 175 (57.75%) did not. The majority 84.2% (n = 255) of the participants were between 18 and 40 years of age and only 105 (41.2%) had utilized the screening services with the majority 150 (58.8%) not utilizing. Most of the participants 144 (47.5%) were married and only 63 (43.8%) of them did utilize the service with the remaining 81 (56.3%) having not utilized. More than half 198 (65.3%) of the study participants had less than five (5) children and only 80 (40.4%) utilized the screening service and the minority 105 (34.7%) respondents with more than five children revealed only 48 (45.7%) utilizing the screening services. Regarding average monthly income, the majority 186 (61.4%) expressed having an average monthly income of less than One thousand kwacha (K1000) and only 62 (33.3%) out of 124 (66.7%) utilized the cervical cancer screening services.

Relating to knowledge, the majority 217 (71.6%) had inadequate knowledge and only 86 (28.4%) had adequate knowledge and amongst the respondents with adequate knowledge, 65 (75.6%) utilized the services with only 21(24.4%) having not utilized. The results also indicated that, the majority 229 (75.6%) of the respondents were residing at a far distance (more than 5km) from the facility offering cervical cancer screening services and only 88 (38.4%) of them had utilized the screening services whilst the other 74 (24.4%) of the respondents staying near the facilities offering screening services revealed 40 (54.1%) respondents utilizing the screening services.

Out of the overall 175 (57.76%) respondents who did not utilize the screening services, 151 (86.3%) reported having a negative attitude towards Cervical Cancer and its screening services, and the remaining 24 (13.7%) expressed having a positive attitude despite not utilizing the service. Further, out of the overall 128 (42.24%) of the respondents who utilized the screening service 61 (47.6%) had a positive attitude and 67 (52.3%) had a negative attitude despite utilizing the service. From the 98 (32.3%) of the respondents who had attained secondary level, more than half 51 (52%) utilized the screening service and the remaining 47 (48%) did not utilize the service. However, most of the respondents 154 (50.8%) had attained primary level and more than half 101(65.6%) did not utilize the service (Table 1)

Table 1

Demographic Characteristics of respondents
Independent variable	Indicator	Utilization of cervical cancer screening
Independent variable	Indicator	yes	No	Total	Percentage
Age range	40+	23	25	48	(15.8%)
	30–40	51	59	110	(36.3%)
	18–30	54	91	145	(47.9%)
	Total	128	175	303
Marital status	Married	63	81	144	(47.5%)
	Divorced	17	25	42	(13.9%)
	Widow	13	21	34	(11.2%)
	Single	35	48	83	(27.4%)
	Total	128	175	303
Educational level	Tertiary	23	19	42	(13.9%)
	Secondary	51	47	98	(32.3%)
	Primary	53	101	154	(50.8%)
	No formal education	1	8	9	(3%)
	Total	128	175	303
Current employment	Public/private employed	25	23	48	(15.8%)
	Not employed	59	101	160	(52.8%)
	Self employed	44	51	95	(31.3%)
	Total	128	175	303
Parity	< 5/ low parity	80	118	198	(65.3%)
	> 5/ grand multiparous	48	57	105	(34.7%)
	Total	128	175	303
Income	>K3000/ High	36	12	48	(15.8%)
	K1000-3000/ Medium	30	39	69	(22.8%)
	< 1000/ Low	62	124	186	(61.4%)
	Total	128	175	303
Knowledge levels on CC screening services	Adequate Knowledge	65	21	86	(28.4%)
	Inadequate Knowledge	63	154	217	(71.6%)
	Total	128	175	303
Attitude of HIV Positive women towards CC screening services	Positive attitude	61	24	85	(28.1%)
	Negative attitude	67	151	218	(71.9%)
	Total	128	175	303
Distance to the cervical cancer screening facility	Near	40	34	74	(24.4%)
	Far	88	141	229	(75.6%)
	Total	128	175	303
Waiting time to access the service	Less than 30 minutes	44	60	104	(34.3%)
	More than 30 minutes	84	115	199	(65.7%)
	Total	128	175	303

Table 2

**Characteristics associated with underutilization of Cervical Cancer Screening Services**
	Bivariate Analysis		Multivariate Analysis
Characteristics	Crude Odds Ratio (95%CI)	Unadjusted P-value	Adjusted Odds Ratio (95%CI)	Adjusted P-value
1. Location (distance from HF)
< 5km	ref	n/a	n/a	n/a
> 5km	0.53(0.31–0.9)	0.02	0.5 (0.26–0.95)	< 0.036*
2. Education level
Tertiary	ref	n/a	n/a	n/a
Secondary	0.89(0.43–1.85)	0.77	2.2 (0.86–5.66)	0.099
Primary	0.43(0.21–0.87)	0.02	1.3 (0.48–3.43)	0.614
No formal education	0.1(0.01–0.9)	0.04	0.5 (0.04–6.28)	0.599
3. Levels of income
>K3,000	Ref	n/a	n/a	n/a
Between K1,000-K3,000	0.27(0.11–0.58)	0.001	0.22 (0.09–0.54)	<0.001
<K1,000	0.17(0.08–0.34)	0.001	0.16 (0.06–0.37)	<0.001
4. Levels of knowledge
Adequate	Ref	n/a	n/a	n/a
Inadequate	0.13(0.07–0.23)	0.001*	0.27 (0.13–0.54)	< 0.001*
5. Attitude towards cancer screening
Positive	Ref	n/a	n/a	n/a
Negative	0.17(0.1–0.3)	0.001*	0.26 (0.13–0.53)	<0.001*
Abbreviation; CI = Confidence Interval

Utilization of cancer screening services by HIV positive women in Serenje District (n = 303)

This part presents information about utilization of cervical cancer screening services among 303 HIV positive women in the district. Variables addressed include women’s previously screened for cervical cancer and the last time, the respondent utilised the screening services. The results revealed that only 128 (42.24%) of the respondents had utilised the services and the majority 175 (57.76%) had not utilised the screening services. It was further revealed that out of the 128 that utilized the services, 76 (59.4%) of the respondents were found screened within the past 2 years and above whilst, 30 (23.4%) had the test within a period of 12 months (Fig. 1 and Fig. 2).

Facility level characteristics associated with underutilization of Cervical Cancer Screening Services among HIV positive women

To identify the facility level characteristics that were associated with the underutilization of Cervical cancer screening services (CCSS) among HIV positive women in district, the study investigated the association between utilization and probable risk factors of age range, marital status, employment status, educational level, parity, level of income, knowledge, attitude, cultural beliefs, waiting time and distance to the facility.

During Bivariate analysis, out of eleven (11) variables, five (5) met the criterion to be included into multivariable or multiple logistic regression by yielding a p-value of < 0.05. These were education level, average monthly income, knowledge, attitude and distance. Multivariable analysis was conducted and four (4) variables (Attitude towards CCSS, Distance, knowledge, average monthly income) remained significant with a p-value of less than 0.05 (Table: 2).

After adjusting for the confounding effects of all the risk factors such as level of income, cultural belief, attitude, level of awareness, parity, waiting time, education level, age and location the study found that compared to mothers with positive attitude towards screening, HIV positive women with negative attitude are 74% less likely to utilize cancer screening services [AOR: 0.26 (P < 0.001, 95% CI 0.12–0.53)]. Relating to knowledge, the study found that compared to HIV positive women with adequate knowledge 73% of HIV positive women with inadequate knowledge are less likely to utilize cervical cancer screening services [AOR: 0.27 (P < 0.000, 95% CI 0.13–0.54)]. Further, the study found that compared to HIV positive women located at a distance of less than 5Km, HIV positive women located at a distance of more than 5km are 50% less likely to utilize cervical cancer screening services [AOR: 0.5 (P < 0.036, 95% CI 0.25–0.96)].

Furthermore, compared to HIV positive women with high average monthly income of K3000 and above, HIV positive women whose income is low/ less than K1000 are 84% less likely to utilize cancer screening services [AOR: 0.16 (P < 0.000, 95% CI 0.06–0.37)]. It was also revealed that compared to HIV positive women with high average monthly income, HIV positive women who are of middle average monthly income (K2000-K3000), are 78% less likely to utilize cancer screening services [AOR: 0.22 (P < 0.001, 95% CI 0.08–0.54)].

Cervical Cancer Screening Services (CCSS)

Study findings revealed an increased utilization rate of screening services in the district by 25.4% for HIV-positive women, implying 42.2% utilization. However, this finding is very low as compared to the recommended national target of ensuring that 100% of HIV positive women utilize the screening services annually (MOH, 2020⁶⁸). This finding is similar to the study conducted in Hawassa town, Ethiopia where 41.1% was reported (Assefa et al., 2019³⁴) and significantly higher as compared to the studies carried out among HIV positive women in Morocco (9%) (Belglaiaa E et al., 2018⁰²), Gondar (10%) (Nega et al., 2019³⁵) and Addis Ababa (11.5%) (Belete, N et al., 2015³⁶). The slight increase in utilization of the cervical cancer screening services amongst women living with HIV in the district, may be attributed to integration of Cervical Cancer screening services with mobile ART Clinic, spearheaded by Non- Governmental Organizations (John Snow Inc. USAID) within the District Catchment areas. However, the utilization rate of 42.2% is lower than research study findings from Canada (Leece P et al., 2010³⁹) with 58%, England with 85.7% (Ogunwale A, N et al., 2016⁴⁰), and Thailand with 53.9% (Ploysawang, P., et al., 2021⁶²). The possible reason for this variation could be due to differences in socio-demographic and economic status of the study participants as well as the countries health promotional initiatives. These include policies such as improved expansion and access to screening at health facilities, enhanced national-wide advocacy, media campaigns, community sensitization and awareness creation.

Another reason for decreased screening utilization rate in the District may be due to limited distribution of screening service facilities. For instance, the increased utilization in Canada is as a result of universal access to health care including the availability of primary care and specialist physicians (Leece P, et al., 2010³⁹).

Knowledge of cervical cancer screening Services (CCSS)

Cervical cancer remains one of the most common malignancies among women in Zambia. The findings revealed that about 71.6% of the HIV positive women expressed low knowledgeable on cervical cancer and its screening services. Further, the study revealed that compared to mothers with high level of awareness 73% of the HIV positive women were less likely to utilize cervical cancer screening services, the results were significant [AOR: 0.27 (P < 0.001, 95% CI 0.13–0.54)]. These findings are consistent with other studies conducted at a tertiary hospitals in Nigeria (Adibe et al., 2017⁴⁵), rural Nigeria Delta community (Omowhara et al., 2022⁶³), Lusaka Urban District, Zambia (Zulu, 2017⁶⁷) Meknes-tafilalet region, morocco (Selmouni et al., 2015¹⁵), Portugal (Laranjeira et al., 2013⁶), and Southern India (Ghosh et al., 2020⁶⁴) that reported lack of knowledge and awareness about cervical cancer among HIV-positive women being the major contributors of low utilization. The reasons for inadequate knowledge on screening services in Serenje District might be attributed to lack of a planned schedule on information dissemination at facility level, lack of community outreach awareness creation as well as low community and facility sensitization on cervical cancer and importance of screening services. This is in line with a study from Vhembe district, South Africa, which reported that cervical cancer screening services can be utilized better if awareness campaigns were sustained and the services were accessible (Vhuromu et al., 2018¹³). Another study by fetters (2020), also confirmed that women’s knowledge of cervical cancer and screening influence the decision to be screened (Fetters et al., 2020⁵³). In Zambia, the other reason may be due to limited time spent between the provider and the client, as cervical cancer screening services are usually incorporated with other activities, such as the ART Clinic. The majority of women are referred for screening services from ART departments thereby considering them already being aware of the program.

Our findings are to some extent consistent with the results of a previous systematic review, which analyzed the barriers associated with cervical cancer screening uptake in Low Middle Income Countries. It was revealed that Lack of knowledge and awareness was among the most commonly reported factors influencing women’s decision to undergo cervical cancer screening services (Devarapalli et al., 2018⁶⁶). In another review by McFarland et al., (2016³¹), which evaluated barriers to Pap test screening among women living in sub-Saharan Africa, it was reported that barriers such as lack of knowledge and awareness about Pap test, belief of not being at risk for cervical cancer, and that a Pap test is not important unless being symptomatic were at the root of not being screened.

In contrast, studies in Malawi (Mtengezo, 2019²⁶), South Africa (Maree etal., 2015⁴⁶) and Kenya (Njoroge et al., 2015⁴²), where HIV-positive women were well informed about cervical cancer and screening services contributed to increased utilization. Further, findings were inconsistence with studies from England (Coleman et al., 2016⁴⁰), Japan (Toyoshima et al., 2017⁴³) and China (Leung et al., 2010⁴⁴) were HIV positive women were found to have increased knowledge. This difference might be attributed to the fact that these countries have effective national cervical cancer screening policies, which include on-going mass campaigns about cervical cancer and its screening services on the radio and television as well as increased health promotion messages both at facility and community levels.

Attitude of HIV positive women towards cervical cancer screening services (CCSS)

The study revealed that 218 (71.9%) of the 303 respondents had negative attitude towards cervical cancer screening services and that, compared to mothers with positive attitude towards screening services, mothers with negative attitude are 74% less likely to utilize cervical cancer screening services and the results were significant [AOR: 0.26 (P < 0.001, 95% CI 0.12–0.53)]. This finding is slightly similar to a study conducted in Ilorin, North Central Nigeria which demonstrated that respondents who had negative attitude had 63% lesser odds of being screened compared to those who had positive attitudes towards screening (Idowu et al., 2016⁴⁷). Therefore, having a negative attitude towards cervical cancer screening services contributed to underutilization of the screening services in the district. The possible reasons for the negative attitude may be attributed to fear of being attended to by a male member of staff, fear of the outcome of the cervical cancer screening test, fear of being attended to by a member of staff whose younger than the client seeking the service and not seeing the need for screening services as they are not sick or having any signs and symptoms suggesting cervical cancer. In support, another study on utilization of cervical cancer screening services in Vhembe district, Limpopo province of South Africa, reported women having a negative attitude towards the screening services as a result of feeling embarrassed to show private body parts to a male health worker and fear of pain and the majority 73.2% not viewing themselves as being vulnerable to cervical cancer thus contributing to underutilization of the screening service (Vhuromu et al., 2018¹³).

Studies conducted in Eastern China (Ratcliffe et al., 2017¹²), Mekelle, Northern Ethiopia (Bayu et al., 2015⁴⁸), Gondar Northwest Ethiopia (Erku et al., 2017³⁸), Hawassa town, Ethiopia (Assefa, 2019³⁴), and Finote Selam town, Ethiopia (Geremew et al., 2018⁴⁹) reported a positive association of having a positive attitude with increased utilization of Cervical Cancer Screening. The reason might be having a positive attitude is mostly followed by having an understanding of the importance of cervical cancer screening and its associated risk, therefore, engaging in cervical screening utilization as well. Additionally, this was consistent with the report that a perceived severity and threat of Cervical Cancer, perceived benefits, perceived self-efficacy, and net benefit of the preventive action of Cervical Cancer and its screening, necessitate people to engage in preventive actions like Cervical Cancer Screening service utilization (Maddux et al., 1983⁶¹).

Accessibility of cervical cancer screening services

The results indicate that the majority 229 (75.6%) of the HIV positive women by health facility had low geographical accessibility (distance more than 5km) to cancer screening services provided in selected facilities. Similarly, a study conducted at a local university in Malaysia (Al-Naggar et al., 2010⁶⁵), Zimbabwe (Mupepi et al., 2011¹⁸) and Tanzania (Beran et al, 2012¹⁴) revealed limited accessibility or inaccessible health facilities because of distance as a major contributor to low uptake of the service among rural women. In South Africa transportation and geographical location impacted negatively on the utilization of cervical cancer screening, especially in area where women needed to travel more than five kilometers on mountainous roads (Vhuromu et al, 2018¹³). Long distances to the nearest health facility and poor diagnostic capabilities of health centers might deter a person from seeking medical attention, enhancing the opportunity for disease progression (Nyirongo et al., 2019¹⁶). In this study, the majority of the respondents came from distant locations; more than five kilometers and the district had a large catchment area, comprising rural communities. This might have contributed to lower utilization of cervical cancer screening services. Therefore, the District should consider the use of screening camps in order to take the services as closer to the communities as possible without waiting for the women to come for the services at the facilities.

Study Limitations

The quality of the care received during screening was not investigated, therefore we do not know if the care received was adequate. This would be an important area to study in the future as having high utilization cervical cancer screening service is also effective if the care being received is of a good quality.
Service related factors such as staff attitude and availability of the services was also not assessed. This has an influence on utilization of health services.

The findings from this study show that there was inadequate utilization of cervical cancer screening services among HIV positive women in Serenje District of Zambia. The key determinants associated with the utilization of the screening services were distance to healthcare facility, Low levels of knowledge, waiting time and attitude of women. These findings should be taken into consideration by policy makers to design and deliver strategies that target women who are at a high-risk.

Health personnel’s working at the Health facilities should intensify targeted and individualized health education on cervical cancer screening services during clinical contacts.
Community Based Organisations (CBOs) should be adequately equipped with knowledge about cervical cancer and importance of screening services, so that they can in turn sensitize communities on cervical cancer.
The District Health Office should consider including outreach awareness creation and screening camps in order to take the services as closer to the communities as possible unlike waiting for the women to come for the services at the facilities.
The District Health office or Provincial Health Office should design and implement information communication and education campaigns on cervical cancer screening services through media, women groups and involvement of influential people in communities’ e.g. Headmen’s, civic leaders, the clergy, local Chiefs.
The Provincial and District Health Office should put in mechanism that can enhance monitoring of the screening services as well as information dissemination.
The Government should consider employing more health practitioners to improve the staffing levels in the selected facilities so as to reduce waiting time by clients e.g. Midwives, Nurses, clinical officers etc.
More funding should be allocated towards the fight against cervical cancer so that sensitization programs by health workers can be taken closer to the people who need them.

CC Cervical Cancer

CCS Cervical Cancer Screening

CCSS Cervical Cancer Screening Services

CDC Centre of Disease Control and prevention

HPV Human Papillomavirus

ICC Invasive Cervical Cancer

MoH Ministry of Health

VIA Visual Inspection with Acetate

WHO World Health Organization

HIV Human Immunodeficiency Virus

UNAIDS Joint United Nations programme on HIV/AIDS

LMIC Low Middle-Income Countries

Acknowledgement

I am greatly indebted to Dr P. A. Bwembya, my project supervisor, for her tireless guidance, critique, patience, support and encouragement that made this work possible. I acknowledge the University of Zambia for providing me with an opportunity to pursue this degree in our locale. Special thanks to the lecturers and Staff of school of Public Health for the tireless efforts and dedication during the course. Lastly my appreciations go to my close circle of friends and Family

Ethical and Cultural Consideration

Ethical clearance was obtained from the University of Zambia, Research Ethical Committee (UNZABREC) and authority from the national health research. Further the request was made to the District Health Office in Serenje to allow collecting data from the institution in the district. Since this study involved human subjects, verbal and written consent was sought from the study participants. Those who declined to take part in the research were not coerced and all respondents were free from emotional danger or harm.

Funding

Not applicable

Consent for publication

Not applicable to the study

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author and the University of Zambia on reasonable request.

Competing interests

The authors declare no competing interests in this study.

Authors’ contributions

All authors contributed to the study conception and design. Data collection and analysis performed by MSM.

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Factors associated with underutilization of cervical cancer screening services among HIV positive women in Serenje District, Central Province

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